Rescission Of Paternity Acknowledgement Form
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1NO. _________________________
IN THE DISTRICT COURT
PETITIONER
JUDICIAL DISTRICT
RESPONDENT
{COUNTY, STATE}
RESCISSION OF PATERNITY ACKNOWLEDGEMENT
Child Name:
Birth No.
Birth Place:
DOB:
Address:
City:
State:
Zip:
Mother Name:
SSN:
Marital Status:
DOB:
Address:
City:
State:
Zip:
Putative Father Name:
SSN:
Marital Status:
DOB:
Address:
City:
State:
Zip:
I,
, declare under the penalty of perjury that the paternity acknowledgement
submitted on
is null and void and should be considered fully rescinded.
Petitioner Signature
Date
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